Keeping the “best care” option out of the health spending equation

Feb. 27, 2013 — If there is a single message that has come to dominate the debate over health care in the United States in the last several years, it is that Americans are receiving too much of it.

The idea that there is rampant “overutilization” of medical services in the U.S. health care system has been embraced by top officials in the Obama administration, by the Institute of Medicine, and by economists and policy experts of all stripes.

“You can name any disease or condition that you want, and I can guarantee that there’s underutilization of an effective treatment happen- ing. The literature is replete with studies that show people not getting things they should be getting.” — Patrick Alguire, American College of Physicians.

The appeal of this idea to policy makers who are focused on reducing the federal deficit is clear: once it is accepted that overutilization is a serious problem, it is a small step to claim that we would save a significant amount of money merely by providing the “right” amount of care. We could, the argument goes, cut out a lot of fat without any risk to our health.

“There are a lot of tests done, a lot of procedures, a lot of hospital admissions which we really know scientifically cannot help the patient,” Donald Berwick, the former administrator of the Center for Medicare and Medicaid Services in the Obama Administration, said in a 2009 interview prior to his appointment to that position, ”I think working hard on the overuse of ineffective practices is a very good way for us to save money and not harm a hair on a patient’s head.”

Much of health care policy, public and private, in the last several years proceeds from (or is rationalized by) this premise. The Patient Protection and Affordable Care Act (ACA), for example, includes an excise tax on relatively expensive health insurance plans, often referred to as the “Cadillac tax.” The tax is intended to make the most generous plans less so, on the theory that people with those “luxury” plans are selfishly and heedlessly consuming too many medical services.

But a thorough examination of the argument by Remapping Debate found only limited direct evidence of “overutilization.” We also found that the claim that utilization could be reduced at no risk to patient health has been oversold.

In many cases, the investigation found, the argument for reducing costs ignores the question of how to provide the best care to the greatest number of people and does not grapple with under-utilization of medical care (a problem that is more widely acknowledged by experts than is generally realized). The argument, it would appear, is based principally on the assumption that we have “no choice” but to cut back on “unsustainable” levels of health care spending, with little concern paid to whether fat or muscle is being cut.

The missing option

According to several experts and observers, demoting or ignoring “best quality” concerns is not a trivial matter. Jonathan R. Cole, a sociologist and a professor of the university at Columbia University, pointed out that transparency is an essential element of public policy decision-making. Choices, he said, need to be presented “in a way that is [at least] conducive to deliberative outcomes” in a democratic society.

Different people will have different definitions of what constitutes “gold standard” care, he said, but “simply articulating what that standard is and making sure one can [analyze its component parts closely] would be very helpful.”

“If a society wishes to spend a lot of its resources on the health of its people…the society ought to be able to increase its part of GDP that goes to health care, especially [if] it has an aging population, which will get rebalanced at some point in time.” — Jonathan R. Cole, Columbia University

Cole, while arguing strongly in favor of more rigorously evaluating the efficacy of various medical procedures, rejected the notion that there is only a single policy choice when it comes to spending on health care: “If a society wishes to spend a lot of its resources on the health of its people…the society ought to be able to increase its part of GDP that goes to health care, especially [if] it has an aging population, which will get rebalanced at some point in time.”

Those considerations along with similar quality-of-care and healthfulness-of-society concerns expressed by other observers, are, Remapping Debate found, precisely the ones that have been absent from mainstream debate and discussion about health care.

James Colgrove is an associate professor of sociomedical sciences at Columbia University’s Mailman School of Public Health. Asked about the need to identify what would be required of a health care system in order to secure for each person all beneficial follow-on medical interventions, Colgrove noted that the question had both an empirical component and an ethical component, the latter derived from a sense of “what it is that is due to people” according to a theory of justice. Whether the empirical discussion should precede the ethical discussion, or, as Colgrove suggested, the ethical discussion should come first, the reality, he agreed, was that both of those discussions are being left out of current political debate.

Colgrove added that the idea that “demagoguery passes for public debate” in the health care context “hits the nail on the head.” Discussions are warped, he continued, by dominant cultural beliefs about individual responsibility and what the “quote-unquote ‘free market’ does, or should do for us.”

“It is,” Colgrove concluded, “a deeply ingrained part our of our political culture that we treat health care like a commodity.”

What happens if the United States just proceeds with various cost-cutting schemes without examining what an alternative system would look like and cost if it provided the kinds of quality care that people would want for themselves and their families (given our current state of knowledge)? It is a fair summary, Professor Cole said, to describe such a process as one that deprives the public of the ability to know what policy options it is being asked to give up — precisely because not all of the options are allowed to be visible.